Pruritus (Itching) - HCV Advocate

•hcspFACTsheet•
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HCV – Extrahepatic Manifestations:
Pruritus (Itching)
CD Mazoff, PhD, Managing Editor
Pruritus is one of the most common symptoms
reported by people with hepatitis C (20%), but
is more commonly found in people with advanced
liver disease and cirrhosis. Pruritus is
itching that may be localized to a specific part
of the body such as hands and feet, but it can
also be a generalized itching all over the body.
Some people even report that it feels like their
internal organs itch. Pruritus can be related to
high bilirubin levels, autoimmune disease or dry
skin, and can be a side effect of treatment. Use
of moisturizing lotions, oatmeal baths or lotions,
antihistamines, and cortisone creams and opiate
drugs can help.
Recent studies are showing that dermatologic manifestations,
and pruritus in particular, may be the only sign of
chronic HCV; therefore it is important that health care
professionals be aware of extrahepatic dermatologic
manifestations, of which pruritus is an example.* Experts
believe pruritus in people with liver disease is due to the
accumulation of toxins (such as bilirubin) that are not
effectively processed or filtered by the damaged liver.
One function of the liver is the production of bile, which
helps digest fats. Cholestasis, or blockage of the flow
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of bile through the liver, can result in a build-up of bile
acids and bilirubin in the blood. High bilirubin levels cause
jaundice (yellowing of the skin and eyes), and pruritus is
common in people with jaundice. Certain extrahepatic
(outside the liver) conditions associated with HCV, such as
autoimmune conditions, may also lead to itching. More
commonly, itching due to dry skin can be a side effect of
treatment with interferon/ribavirin; this is not the same
as pruritus due to advanced liver damage.
Pruritus symptoms can range from annoying mild itching
to severe itching that interferes with daily life. Often the
itching is worse at night, and may prevent sleep. Simple
scratching typically does not relieve pruritus. As a result,
some people risk skin infection and injury by scratching
themselves with sharp objects.
Certain drugs can help reduce itching, particularly classical
analgesics for neuropathic pain (gabapentin, antidepressants)
which also exhibit antipruritic efficacy upon
clinical use. Some people find that antihistamines, such
as diphenhydramine (Benadryl) or hydroxyzine (Atarax),
help relieve symptoms and allow better sleep.
For pruritus due to cholestasis, cholestyramine (Questran)
and colestipol (Colestid) may be effective. These drugs
are bile acid binders that attach to bile acids in the blood
and help eliminate them from the body. They can also
interfere with the absorption of other medications, so
other drugs should be taken at least two hours before or
after bile acid binders.
Some studies have shown that opiate antagonists such
as naloxone (Narcan), naltrexone (Revia), and nalmefene
(Revex)–which are used to block the effects of opiate
drugs–can also reduce severe itching. Phenobarbital
(Luminal), ondansetron (Zofran), and ursodiol (Actigall)
may also be used, and several other medications are
under study.
Rifampin, a hepatic enzyme inducer, is effective for the
pruritus of cholestasis, but caution should be used in patients
with preexisting liver disease because of possible
HCSP • VERSION 2.2 • June 2010 1

hepatotoxicity. Butorphanol has also been shown to
be effective in suppressing cholestatic pruritus. Zoloft
(Sertraline), an antidepressant often prescribed to people
with hepatitis C, is also effective in reducing the itching
caused by cholestatis.
Another way to reduce itching is to stop smoking if you do
smoke tobacco. Not only does smoking possibly affect the
sustained virological response to interferon (IFN) therapy,
but it can also lead to “Smoker’s Syndrome,” which is
characterized by episodes of facial flushing, warmth of the
palms and soles of feet, throbbing headache, fullness in
the head, dizziness, lethargy, prickling sensation, pruritus
and arthralgia (joint pain).
Experimental treatments for pruritus include plasmapheresis
(in which blood plasma is removed, filtered, and
returned to the body) and ultraviolet (UV) light therapy.
Liver transplant is the only cure for severe itching in
people with advanced liver disease. For most people
with less advanced hepatitis C, though, practical measures
and medications are often sufficient to overcome
the itch.
Tips for combating dry skin and itching:
♦♦
Avoid soap. Use a non-soap cleanser such as
Cetaphil or a similar substitute
♦♦
Try rubbing, vibration, or applying pressure instead
of scratching. A good thing to “scratch” with is an
ice cube
♦♦
Drink plenty of water or other clear fluids to keep your
entire body hydrated
♦♦
Apply moisturizer immediately after a shower or bath
– before drying off with a towel
♦♦
Creams are more effective moisturizers than lotions
♦♦
Apply moisturizer at least twice a day. Effective
moisturizers include Vaseline Intensive Care, Aveeno,
Eucerin, and Lubriderm
♦♦
Use only non-perfumed, mild bath and personal care
products
♦♦
Avoid extremely hot showers and baths
♦♦
Take an oatmeal bath to relieve itching and help with
relaxation
HCSP • VERSION 2.2 • June 2010
♦♦
Try baking soda or unscented bath oils for bathing
♦♦
Apply cold packs (wrapped in a towel) to the skin
♦♦
Whenever possible, wear loose fitting clothes made
from natural fabrics that breathe
♦♦
Protect your skin from the sun – wear sunscreen
♦♦
Look after your lips – use lip balm with sunscreen
♦♦
Get plenty of rest
♦♦
Keep rooms ventilated and at a temperature of 60
to 70 degrees
References
Portions of information appearing in this article are excerpts
written by Liz Highleyman (“Pruritus: Dealing with
that Itch,” HCV Advocate, March 2003), and Lucinda Porter
and Alan Francicus (A Guide to Hepatitis C Treatment
Side Effect Management, HCSP Publications, 2009).
*Soylu S, Gül U, Kiliç A. Cutaneous manifestations in patients
positive for anti-hepatitis C virus antibodies. Acta
Derm Venereol. 2007;87(1):49-53
See also: Pruritus and Systemic Disease, by David F
Butler, MD, and Jared J Lund, MD. http://emedicine.
medscape.com/article/1098029-overview
For more information about hepatitis C, hepatitis B and
HCV coinfections, please visit www.hcvadvocate.org.
Executive Director
Editor-in-Chief, HCSP Publications
Alan Franciscus
Design
Paula Fener
•hcspFACTsheet•
A publication of the Hepatitis C Support Project
Production
C.D. Mazoff, PhD
Contact information:
Hepatitis C Support Project
PO Box 427037
San Francisco, CA 94142-7037
alanfranciscus@hcvadvocate.org
The information in this fact sheet is
designed to help you understand and
manage HCV and is not intended as
medical advice. All persons with HCV
should consult a medical practitioner for
diagnosis and treatment of HCV.
This information is provided by the
Hepatitis C Support Project • a nonprofit
organization for HCV education, support
and advocacy • © 2010 Hepatitis C
Support Project • Reprint permission is
granted and encouraged with credit to
the Hepatitis C Support Project.
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